ENROLLEE CLAIMS SUBMISSION
GENERAL INFORMATION If you receive services from a Participating Provider (as published in the Provider Directory), the Health Plan will pay the Health Care Provider directly for all care received. You will not have to submit a claim for payment and will be responsible only for any applicable deductibles, copayments or coinsurance. However, there may be a time when you, instead of your Provider or Pharmacist, need to submit a claim requesting payment for services that have been received or for prescription drugs. REIMBURSEMENT FOR MEDICAL EXPENSES You should rarely need to file a claim since participating providers will submit claims for you. However, if you receive medical care from non-participating providers, you may be required to pay for the services yourself and request reimbursement later. While it is preferable to have your provider submit a valid claim form to us, you can also request reimbursement by sending us a written medical reimbursement form which should include the name of the Insured, the policy number, and the Insured’s signature. An itemized receipt for the services or supplies rendered, with details regarding diagnosis and/or reason for the services along with a written proof of payment made, should be submitted with the form. The request for reimbursement and itemized bill must be submitted within six months for commercial members. We will reimburse you according to your benefit plan allowed time frame. If reimbursement is denied for any reason, you will receive an Explanation of Benefits (EOB) that explains why. Please send your reimbursement request to: Health First Health Plans - FHCA Attn: Claims Department 6450 US Highway 1 Rockledge, FL 32955 Send original documents, but keep copies for your own records. REIMBURSEMENT FOR PRESCRIPTION DRUGS If you have to pay for prescription drugs yourself for any reason, you can be reimbursed according to the provisions of your plan. If you are due a reimbursement, simply send your detailed pharmacy receipt to us along with completed a Prescription Drug Reimbursement Form within 180 days from of the date of service. Be sure to include the name of the Insured, the policy number, proof of payment and a copy of the receipt that is attached to your medication bag at the time of purchase. A Pharmaceutical Services Department (PSD) representative will review paper reimbursement requests for prescription claims and process all complete requests for payment within 14 days of receipt by the Health Plans. We will reimburse you the pharmacy’s contracted rate minus any applicable cost share. Your reimbursement request can be faxed to 1.855.328.0061 or mailed to: Health First Health Plans Attn: Pharmacy Department 6450 US Highway 1 Rockledge, FL 32955 Please do not send original documents
36194_MPINFO323FH (08/2017)
ENROLLEE CLAIMS SUBMISSION
WHERE CAN I FIND REIMBURSEMENT FORMS? Reimbursement forms are available on the Health Plan’s website at myFHCA.org and through the Member Portal. Forms may be requested by calling the Health Plan’s Customer Service Department. QUESTIONS If you have questions about your health benefit plan, there are several ways to contact us to obtain the assistance you need: By telephone If you have questions about your plan or need assistance in a language other than English, please contact Customer Service. Toll-free: 1.844.522.5279 TDD/TTY: 1.800.955.8771 Our Customer Service hours are: Monday through Friday from 8 a.m. to 5 p.m. By email Send your questions or comments to:
[email protected]. By fax Send your fax to: 1.855.328.0062 By mail Send correspondence to: Customer Service Health First Health Plans - FHCA 6450 US Highway 1 Rockledge, FL 32955
Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
36194_MPINFO323FH (08/2017)
